Healthcare Provider Details

I. General information

NPI: 1477427961
Provider Name (Legal Business Name): CAPTIVATE PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2025
Last Update Date: 09/30/2025
Certification Date: 09/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2052 RICHMOND RD
STATEN ISLAND NY
10306-2583
US

IV. Provider business mailing address

2052 RICHMOND RD
STATEN ISLAND NY
10306-2583
US

V. Phone/Fax

Practice location:
  • Phone: 718-667-2190
  • Fax:
Mailing address:
  • Phone: 718-667-2190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: MS. NICOLAS CAMPBELL
Title or Position: BUSINESS OWNER
Credential: DPT
Phone: 609-670-7759